Sunday, June 30, 2013

Doctor's can't help fix the health care cost problem because they are kept uninformed about prices or (worse) not allowed to disclose prices to patients or journalists (or health care researchers) once those prices become known to them lest they lose their job.

So, for example, there might be a technology a doctor wants to use to make a diagnosis on one of his patients.

Later he learns that his patient was charged many thousands of dollars for that simple diagnostic test because his patient informs him that the insurance company considered the test "unproven or experimental" and refused to pay for it.

Not only is the charge for the test exorbitant relative to the work required to perform it, but the doctor also learns that every local insurer will not pay for the simpler test he ordered but will pay for an invasive surgical procedure to gather the same exact same data at ten times the cost.

What should the doctor do now?

Should they refer future patients for the diagnostic surgical procedure that pays him and his employer well yet costs the patient very little, or should they do the least invasive and safest test to gather the data knowing their patients will be left with a hefty overpriced bill that will not be covered by their insurer?

For the solution to this problem, I'd refer the reader to the first sentence of this piece.

* * *

In the past when the majority of doctors were independent from large health care systems, doctors could advocate for their patients and move them to other centers that offered cheaper prices or had superior services. Now it is estimated that nearly 75% of physicians will be employed by hospitals or large health care systems by 2014. This may sound reasonably benign and irrelevant until patients contemplate what they are trusting their doctors to do.

If the issue of quality and price transparency are important parts of our health care reform discussion, then another solution for reform than our present construct will have to be developed.

After all, with the passage of our new health care law (and its "accountable care organization" construct), it is becoming crystal clear that we have approved a system that perpetuates the impossibility of doctors serving as true advocates for their patients.

Wednesday, June 26, 2013

With the rapid dissemination of medical information, global reach of the internet, and realization that more print journals doesn't mean better print journals, today's researchers use a variety of techniques to connect but most, sadly, have not kept pace with the times.

Yesterday, watching the nightly news, I saw something that caught my eye. It came during a story about yet another shooting in Chicago. The usual folks were interviewed by the media: distraught family members, friends, and eye witnesses to the crime. One of the witnesses seemed intelligent, articulate, and surprisingly insightful and there, below his name on screen, was his Twitter handle.

Imagine how researchers could connect if Twitter accounts were added to their author lines in journal articles or next to their e-mail address in the article's contact information section. Like-minded researchers could instantly connect, follow colleagues with similar interests, or message them questions. Private conversations could continue via direct messaging or e-mail in follow-up. Such a system would easily connect like-minded scholars as well as promote an individual's work. Just as TV stations, news organizations, professional scientific organizations and the entertainment world have embraced the trend, so too should our stodgy academic world.

And why not?

After all, everyone's looking for research funding these days.

Who knows? Good scientific work might just have a chance of receiving funds from the most unlikely of sources thanks to social media.

Tuesday, June 25, 2013

Could the honey from bees cause cardiac arrhythmias? At least one European Heart Society abstract, already fed by press release to the "inter-Webs," suggested it could:

Dr. Ugur Turk, from Central Hospital, Izmir, Turkey, reports on the cases of a 68 year old father and 27 year old son who were both admitted to the Izmir emergency department at the same time with symptoms of vomiting and dizziness. Surface ECGs revealed both patients to have complete atrioventricular block and atrial flutter with slow ventricular responses. When a history was taken both father and son reported that their breakfasts over the past three mornings had included high amounts of honey from the Black sea region of Turkey. This information immediately triggered Turk and colleagues to consider that their patients could be suffering from 'mad honey poisoning'. Mad honey poisoning occurs after people consume honey contaminated with grayanotoxin, a chemical contained in nectar from the Rhododendron species ponticum and luteum. Grayanotoxin is a neurotoxin that binds to the sodium channels in the cell membrane, maintaining them in an open state and prolonging depolarisation. "It's like the effect of cholingeric agents, and results in stimulation of the unmyelinated afferent cardiac branches of the vagus nerve which leads to a tonic inhibition of central vasomotor centres with a reduced sympathetic output and a reduced peripheral vascular resistance,"says Dr. Turk, "This in turn triggers the cardioinhibitory Berzold-Jarisch reflex which leads to bradycardia, continued hypotension, and peripheral vasodilatation."

Mad honey poisoning generally lasts no more than 24 hours, with symptoms of the mild form including dizziness, weakness, nausea, vomiting, excessive perspiration, hypersalivation and paraesthesia. Symptoms of the more severe form include syncope, seizures, complete atrioventricular block and even fatal tachyarrhythmias (due to oscillatory after potentials).

While no specific antidote exists for grayanotoxin poisoning mild cases can be treated with atropine and selective M2 muscarinic receptor antagonists; while for the more severe form treatment options include temporary pacemaker implantation, and vasopressor agents.

Heh. Maybe that explains why the "honey badger don't care." Especially since the testing of the honey consumed by the two individuals only tested for the presence of Rhododendrons and not grayanotoxin.

Monday, June 24, 2013

No where is this more apparent than working to get physicians to understand the potential of social media for their practice. The adoption of social media by doctors - even something as relatively simple as Twitter, is tough.

Face it: Thinking that a re-tweeting how much we want - really - more doctors on Twitter by next year is just preaching to the social media choir. After all, those on social media are already supporters. How do we get physicians who are NOT on social media to understand its potential value to them?

This is not a simple undertaking. Doctors are being forced to spend more computer screen time than they ever wanted to thanks to the mandatory documentation requirements of electronic medical records. What physician also wants to spend even more time glued to a computer screen - or cell phone - texting little tidbits to Twitter, posting pictures to Facebook, or browsing Pintrest photos?

Please.

For doctors to accept social media, they have to understand its value to them. There's only one way I know to do that: demonstrate it to them.

Those of us who are believers have to show them a well-organized RSS feed reader containing journal articles and news reports they're want to say up up to date with and likely read. We have to show them how to use social media to collaborate (in near real-time) with colleagues to write an article or crowd-source a talk. We need to show them the contacts - many who they'd recognize - you've made around the globe. Show them how they can lurk and get the information they need without having to expose themselves to any potential legal issues. We should show new graduating residents and fellows how they can stay in touch with their professors so they can continue to tap their network for answers to difficult clinical questions and get a rapid response. And if all else fails: we must show them how they can stay in touch with their kids once they leave their homes.

Then, slowly, one-by-one, a grass-root physician social media movement can begin. Otherwise, we'll just be preaching to our same old same-old physician social media circle.

Sunday, June 23, 2013

Why are American's being kept in the dark about how much insurance rates will jump once the major provisions of Obamacare are implemented 1 January 2014? How on earth are American's supposed to budget for their health care?

Is it just because the The Secretary of the Department of Health and Human Services is still negotiating the prices with insurers as they flail to set up all of the necessary insurance exchanges?

Or might it be because the price shock is going to be so significant that, politically, it would be unwise to mention?

Or maybe, despite the higher price, coverage won't be so keen after all?

It could be that HHS is keeping a lid on rates because it wants to avoid a California-like debacle.

Last month, California officials crowed that health insurance premiums would fall in their Obamacare exchange. "This is a home run for consumers in every region of California," said the exchange's executive director.

But California officials were off base, according to economists who scrutinized the figures.

Some insurers reportedly controlled costs by cutting out the most expensive hospitals and doctors from their networks and by boosting patients' out-of-pocket payments. "The premiums for the policies that will be offered ... are much higher than analogous plans being sold today," Daniel Kessler, a professor of business and law at Stanford University, wrote in a Wall Street Journal op-ed.

Bottom line: The cost of health insurance in California and the rest of the country will spike for many people, especially the young. At the same time, millions of Americans will be pushed into fledgling, sure-to-be-glitchy exchanges to buy that insurance.

With roughly 100 days before the Oct. 1 opening of exchanges nationwide, federal and state officials have blown deadlines and remain tangled in regulatory confusion, according to twin reports last week from the Government Accountability Office.

Many states running their own small-business exchanges, for example, hadn't finished nearly half the tasks that were supposed to have been done by the end of March, the GAO said. Some states have scaled back offerings to meet the deadline. Others have abandoned the idea of running their own markets and ceded control to the feds.

"Whether (the Centers for Medicare and Medicaid Services') contingency planning will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined," the GAO noted in a rousing vote of no confidence.

The states are scrambling to install a complex system that relies on computers to share data with the Internal Revenue Service, state tax offices, Medicaid, Medicare and other agencies in order to verify customer information. A consultant for Utah's exchange told The Wall Street Journal: "Something will be up and running on Oct. 1. It will be full of issues, bugs and technological challenges." Ack.

The states also need to train tens of thousands of customer service agents to help customers navigate the exchanges. A massive public outreach campaign looms.

Maybe the real reason that politicians are so wary about revealing real insurance costs to America's populace until the last minute is because the curtain of health care costs will rise, in plain dollars and cents, to their electorate.

Suddenly, American's will see that "health care for all" doesn't mean "health care for free." Suddenly, "affordable health care" might not seem so "affordable" after all. Then they'll realize that this law is the most expensive, unread law to ever be imposed on each of us. And that's before the IRS gets involved in making sure we pay for it.

I cleaned house today: a few years of my favorite print journals were stacked high, soon to enter the recycling bin:

﻿
﻿

R.I.P., journal clutter.

﻿
It's funny. As a medical student, I cut out articles and carefully sorted them by topic in manila folders separated by organ systems in a large standup file cabinet for easy reference. I cherished that file system for it contained the latest and greatest articles on whatever topic I needed.

Next came the purview of the really cool docs: bound journals. Boy, did you look bad-ass having bound journals on your shelf (just like those in the library!). It only cost a minor fortune to send them to a binding company, wait several months and, presto, you were as cool as your professors and ALWAYS had the latest articles you needed close by.

But as fast as that moment arrived, it disappeared.

After all, the volume of journals you needed quickly quadrupled, quintupled, and expanded faster than vinegar to baking soda. Stacks and stacks of journals accumulated in my office so quickly that I found I never had time to read them all. So I triaged: New England Journal of Medicine? Nope. Annals of Internal Medicine? Nope. JACC? Sure. Heart Rhythm? Have to have that one. PACE? Not so much.

And on and on it went.

But now, thankfully, there's RSS feeds. And Google.

So goodbye my paper-backed friends, it's been wonderful. Thanks for all the memories and the security of knowing you were there.

"I'm sorry the I chose to be a Blue Cross / Blue Shield provider, Mr. Smith, but I need to determine the money I need to earn, not an insurance company."

"How could you do such a thing? You have an obligation to continue our therapy! I've been seeing you for years! What you're doing amounts to nothing less that patient abandonment!"

"Mr. Smith, I am not abandoning you. I am only saying that under my new construct, I am not willing to take the negotiated price the insurance company wants me to accept. As we have discussed, I am willing to negotiate a reduced rate for you given our history, but I am not willing to see you for less than $100/session."

"You're so damn greedy. How could you do such a thing?"

"Did you really think that I would be willing to continue to see you for only $10 a session? This expectation has created a cost of care bubble expectation that is incredibly destructive to the realities of health care costs today. I would suggest that if you feel this reduced rate of $100/session is not fair that you consider seeing another psychologist. I'll keep your appointment on the books for next week at your regular time. I suggest you think about it, and if you decide to cancel, let me know."

With that, he left in a huff. Forty-eight hours later he called, asking that his appointment be cancelled. She complied and booked another new patient in his place.

* * *

Weeks passed. Then a phone message appeared amongst her many telephone messages:

"Doctor, would it be possible to see you next week at the reduced rate we discussed?"

Tuesday, June 18, 2013

"Doctor, I've been taking my vitals signs and they've been very stable, but recently I've noted I just have no "get-up-and-go." I feel short of breath climbing stairs now. Any idea what might be going on? Here's what I've recorded:"

The patient's self-recorded vital signs(Click to enlarge)

So, what's the diagnosis? (Hint: remember who the patient came to see...)

Thursday, June 13, 2013

How do you quell physician discontent with Electronic Medical Records (EMRs)?

Easy.

Have the leadership of your physician organization interview the National Coordinator for Health Information Technology, then make sure your physicians read the spin. This is one of my favorite excerpts:

Q: Many physicians are not seeing the expected financial return on
investment after EHR implementation. Why is that?

A: How you implement the technology has a lot to do with the results you achieve. (ed: Now, note how he dodges the question) But the bigger issue is how the compensation system is designed. If physicians are operating in a fee-for-service environment, then many of the gains of EHRs -- for instance, in quality, safety and patient engagement -- aren't reflected in revenue. Physicians are doing more work and delivering better care and service, but the added value is not reflected in the reimbursement. (ed: Okay, that's what we said: we're seeing lower pay, not higher, despite doing more and more meaningless data entry work with EHRs. We are often not finding return on our investment with the additional work. Why are you now addressing nebulous issues with physician payment reform? Could you stick with the question, please?)

We've been an advocate for making sure that when value is added, it's reflected in increased physician reimbursement whether it's through the patient-centered medical home (PCMH) setting (ed: Alas: no. It is impossible for the Coordinator to stick to the question. Now we're on to Value-Based Purchasing. WTF? Doctors aren't PURCHASING value, dammit, we're providing CARE!), value-based purchasing or part of an accountable care structure. That's where the ability to manage information -- not just for individual patients but for populations (ed: Remember dear doctor, it's not about you and your patient, EHRs are about the population manipulation! Huh?)-- becomes an absolute necessity, because in those models, it's not a question of whether there's a return on investment with electronic health records. (ed: Yes, dear Coordinator, in case you forgot, this WAS the original question) A physician can't function in those models without an EHR. (ed: Really? Since when?)

If you can stomach more, go on over and read the whole thing. (And consider leaving them a comment about how you really feel about this spin).

Saturday, June 08, 2013

As my head reels at the implications of the IRS scandal mushrooming in Washington, the IRS's recently disclosed ability to access e-mails without warrant, the intricacy of the NSA PRISM wiretap techiques that includes their ability to acquire tech firms' digital data, and even the Justice Department's ability to secretly acquire telephone toll records from the Associated Press, I wonder (as a doctor) what all this means for the privacy protections afforded by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in our new era of mandated electronic medical records. Are such privacy protections credible at all?

It doesn't seem so.

Now it seems everyone's health data is just as vulnerable to federal review as their Google search data. This is not a small issue. We have already seen that discovering "leaks" of personal health information has produced some very handsome rewards for the feds, so it is not beyond reason to think that HIPAA might also be a funding tool for our government health care administration disguised as a beneficent effort to protect the health care data of our populace.

But even more concerning is the role the IRS scandal has for America's health care system. After all, the Affordable Care Act is ultimately funded by the IRS by administering some 47 tax provisions. These include the right to levy a penalty against businesses and individuals who don't provide or acquire insurance and determining how to distribute annual subsidies to 18 million people who make less than $45,000 a year and thus qualify for subsidies in buying health coverage. In addition, the agency will collect taxes on medical devices and a surtax on people making more than $200,000 a year, as well as conducting compliance audits of tax-exempt hospitals.

We are left to wonder: given the IRS's recent actions in favor of one political party, could other aspects of our evolving health care system be similarly politically targeted? What if the government agencies turn a disapproving eye on physician-run hospitals or independent concierge medical practices? What if the market place emergence of a two-tier health care system is systematically crushed? For these types of concerns we instinctually rely on a fair, beneficent government, but these latest revelations challenge that assumption.

To the political class, the ends always justifies the means. Now, we're seeing that the means includes stealth digital tracking, e-mail browsing, and wiretaps.

Health care data protection by HIPAA?

Meh.

We should think about the far-reaching implications of what we're seeing from our government agencies as we turn the reins of health care financing over to them lock, stock, and barrel. Perhaps Peggy Noonan said it best:

What does it mean when half the country—literally half the country—understands that the revenue-gathering arm of its federal government is politically corrupt, sees them as targets, and will shoot at them if they try to raise their heads? That is the kind of thing that can kill a country, letting half its citizens believe that they no longer have full political rights.Those who think this is just business as usual are ahistorical, and those who think nothing can be done, or nothing serious should be done, are suffering from Cynicism Poisoning.

Thursday, June 06, 2013

With yesterday's publication of the 2013 ACCF/AHA Guidelines for the management of heart failure, the 101st guideline for cardiologists since 2005 published jointly by the ACC and American Heart Association appeared in the literature (if my count is correct). Then again, the National Guideline Clearing House set up by our own US Government suggests there are 483 previous guidelines pertaining to cardiovascular diseases, but only 52 published by either the AHA or ACCF for cardiologists. Does ANYONE know how many guidelines there are for us to review and stay current with? Which version should we apply to patient care? When new guidelines are published, how long do we have to implement the new recommendations for care in real life? Given the pace of medical innovation worldwide, are new guidelines already obsolete once they're published?

With so many publications, constantly updated over and over again, each new set of guidelines joins the maw of guideline publications for physicians that are increasingly ignored. Worse, the level of evidence for most guidelines are meager at best. As a result, their importance has been relegated to armament for legal authorities rather than eagerly anticipated recommendations for care. It has also become clear that payors don't follow these guidelines for payment decisions either; instead they turn to their internal corporate medical coverage policies.

It would be helpful to have a "What's New" section in the guidelines but, alas, we must repeatedly endure the rambling preamble that rehashes methodology and hope we don't miss the important stuff contained in these tombs when new versions are published. Despite their effort to be all-encompassing, nuances in complex medical care inherent to sick patients with multiple organ system diseases limit the applicability of these documents in many cases. So doctors practice their art as they always have: with care and compassion and their best clinical judgment.

It's too bad, guidelines were once helpful years ago. Now, clinical doctors are officially numb to them, just like they're numb to ubiquitous telemetry alarms that are overused and constantly ring on our wards.

Tuesday, June 04, 2013

Next week I'll be attending our medical school graduation and I wondered what I would tell them if I were chosen to give them a commencement address. This would not be an easy speech to write right now, given all of the uncertainties in health care that lie ahead, but I thought it would be interesting to try. Readers are invited to add their words as well in the comments section.

Dear Graduating Class of 2013 -

I appreciate the opportunity to address such an impressive pool of medical school attendees. From the first day of medical school when you were introduced to your cadaver, you have endured countless lectures and lab hours, physical examination and sensitivity training sessions, and ward rotations under the watchful eye of senior residents and attendings. Today, you will hold something that few people are privileged to sign behind their name: the letters "M.D."

This time in medicine is both a particularly exciting and particularly challenging one for doctors. How you deal with these challenges will determine your staying power in the profession.

During your training and long hours, you carefully cultivated your taste for fine coffee. At first, time allowed for a daily Venti-sized Starbucks mocha latte, but later as you learned the contributions of carbohydrates to your waist line, you switched to "only" black Ethiopian Harrar. Good for you. No doubt your upcoming days of residency will allow you some time to enjoy these delights a bit longer, but rest assured that by the time you call yourself an attending physician, you will be satisfied to drink a late night splash of automated coffee machine chemicals called "Coffee, Black" as you clean up the remaining work load left by residents who have exceeded the work hour restrictions you once enjoyed yourself. With this graduation, your sheltered medical workshop days are quickly coming to a close.

While most of you think this day is about you, realize there are some very important team players that have helped you get to where you are today. First and foremost are members of your family. They have encouraged you, guided you, and likely funded much of your way to this point. And the funding for medical school has been significant. The average medical school costs today, when one includes living expenses, exceeds $200,000. For those of you who did not have family members supporting you, realize that $200,000 of debt obligations translates to $843.21 per month if you plan to pay that loan off over 30 years at a low 3% interest rate. If your interest rate is higher, I feel for you. Yes, Virginia, medical school has become much too expensive.

But there is some good news. For the first time ever, instead of paying in to the health care education system, the health care system will start "giving back" and paying you. Admittedly at a very low rate. But at least it's your first tiny step in the right financial direction. Hopefully by the end of your residency training, the additional clinical experience you gain will finally allow you to make a bit higher salary than the nurse practitioners you work beside.

Fortunately, each of you began life as a medical student-doctor in the Gilded Age of Information Technology. Anything, you were taught, is possible with enough Big Data. But more data is not always better data. More data can confuse and obfuscate. More data might not be important data. And all that data comes at a cost to you: repetetive motion injuries. You see, Big Data is created from the information you will be asked to enter on your keyboard, iPAD, or via mouseclick or Google Glass. And since Big Data must now include a myriad of new procedure and diagnosis codes that you must learn, residency is not only a time to master disease states, but also a time to master your typing and coding skills. What ever you do, don't let Big Data detract from what matters most: your patient.

Your greatest challenge as a newly minted doctor in this Information Age will be to put your cellphone down. Looking up from its glowing screen will let you see your patient's downward stare as they tell you their deepest, personal secrets. If recognized, a trusting doctor-patient relationship will blossom. If missed, a feeling that you don't care may result. Remember that despite what the information technology zealots have been telling you, patients are not digital widgets, but analog, non-linear, feeling creatures who demand respect and intelligence. If you remember this, you will go far.

Many of you will be switching to new cities and new institutions to begin your residency training at a highly-esteemed medical school now that you've "matched." As you work to learn the clinical side of medicine, stay flexible. Fellowship positions are getting harder to come by as cuts to income for specialists continue. So hang on to those cardboard moving boxes - they might be needed sooner than you think. Honing hospitalist skills will probably be a wise choice, too.

And be prepared to have your heart broken. People will die despite your very best efforts. Complications occur, even to the most skilled and most cautious. Administrators will tell you to do things a certain way when you know that way's inefficient, but it pays your salary. People will deny payments for things that you know they shouldn't. A single malpractice lawsuit, even if ultimately found to be unwarranted, will forever change you - not for the better - but for the worse. And your wife and kids will still be affected when you arrive home late after missing your daughter's dance recital even though she says, "That's okay, Dad."

An example of a few much-appreciated
thank-you notes you'll receive
(Click to enlarge)

But despite all of these realities, there remain some wonderful aspects of medicine. People still will look up to you. People will still respect what you do and say. People will trust you, confide in you, and appreciate your efforts. You can do amazing things for people if you don't let the system get you down. Get involved in the process. Work to set the needs of your patients before that of the system and you'll usually be rewarded.

Because in the end, this is what really matters.

So go forward, not with an artificial glow about all that you have achieved, but with the stark reality of what lies ahead. These are challenging times for doctors as we increasingly encounter efforts to devalue all we've learned and experienced. Work to make the system better. Stay strong, work hard, and appreciate all you've got.

After all, there's plenty of people who would give anything to be in your shoes.

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.